[But Pakistan ’s family-planning efforts have lagged far behind those of
other large Muslim - majority nations, including Iran and Bangladesh . In those countries, governments have stuck to
population-control policies and backed them with money and political will, according
to researchers. In Pakistan , where the powerful military consumes a large chunk of the
budget and development spending has stagnated, family-planning efforts have
consistently fallen victim to tumultuous and weak governance.]
By Karin Brulliard
MIRWAH, Pakistan —
Shazia Shahid, a community health educator, went to the tiny house to speak
with the slight young woman about birth control. It was morning, a good time
because the woman’s husband was out working. But the woman shrank behind a
green veil — and behind her wizened mother-in-law, who smiled but made clear
that she saw no need to discuss the topic.
It was a typical
exchange in this remote village, and in much of the nation. In fits and starts,
public and private agencies in Pakistan are advocating contraception to curb the country’s surging
population, prevent deaths during childbirth and help provide better lives for
those who are born. But in this deeply conservative society, women themselves
are often the least able to decide, and the people who can — husbands, mullahs,
mothers-in-law — still prize many children, particularly boys.
It is a desire that
“Do we want to become
the fifth-largest nation with large segments of the population falling below
the poverty line who are uneducated and unhealthy?” Prime
Minister Yousuf Raza Gilani said
on World Population Day in July.
But Pakistan ’s family-planning efforts have lagged far behind those of
other large Muslim - majority nations, including Iran and Bangladesh . In those countries, governments have stuck to population-control
policies and backed them with money and political will, according
to researchers. In Pakistan , where the powerful military consumes a large chunk of the
budget and development spending has stagnated, family-planning efforts have
consistently fallen victim to tumultuous and weak governance.
Today, just one in five
Pakistani women ages 15 to 49 uses modern birth control. Contraception is
shunned under traditional social mores that are fiercely defended as
fundamentalist Islam gains strength.
Yet religion is hardly
the main obstacle, public health workers say. Although some clerics scorn birth
control, health workers have persuaded other imams. The bigger cultural
hurdles, the workers say, are husbands and mothers-in-law, as well as the
inability of many women to make decisions for themselves.
Young brides commonly
live with their husbands’ families after marriage. In most such units, the
mother-in-law runs the house. If a health educator stops by, the mother-in-law
must first be approached, as Shahid experienced in Mirwah.
“So what? I will take
care of the children,” the mother-in-law, her arms covered in bangles, said
when Shahid expressed concern that the daughter-in-law, still a teenager, was
not using birth control.
Leaving the house,
Shahid — who works for Greenstar Social Marketing, a
nongovernmental organization that trains health providers and markets
subsidized contraceptives — vowed to woo the mother-in-law in successive
visits.
“Slowly, I will
convince the people,” she said.
Rates of contraceptive
use are particularly low in rural Pakistan , which is home to two-thirds of the about 180 million
people in the nation. In this area of Sindh province, literacy rates are
dismal, teenage marriage rates are high, and 10-children families are not
uncommon.
Over 50 years, Pakistan ’s fertility rate has dropped from about six children per
woman to an average of about four. But the decline has been far too slow for
the country to reach its target of 2.2 children per woman by 2020.
Even in Sindhi deserts
and the northwestern mountains, Pakistani women have heard of modern
contraception, survey data show. That is in part because government and private
health agencies, some funded by U.S. assistance, have churned out advertisements featuring
jingles about condoms and vignettes about couples visiting health clinics.
These days, the
campaigns emphasize “birth spacing,” or waiting three years between births — a
message that family-planning programs emphasize is endorsed by the Koran, which
encourages breast-feeding for 24 months.
But men are difficult
to convince, health workers said. At a men’s meeting in Mirwah, a man with a
cigarette dangling from his mouth and a baby in his arms stormed away,
muttering that birth control amounted to “interfering in God’s ways.”
Others said they were
unopposed but uninterested. “Our mothers, they are the deciding figures,” one
man said. “Our wife? What does she know?”
The government says it
is committed to slowing population growth, which it referred to in a report
last year as a “major impediment to [Pakistan ’s] socioeconomic development process.” But public health
experts say they have seen little beyond lip service.
In rural areas, access
to family-planning services is limited and hampered by deteriorating security,
while government health workers are overburdened. International donors want
bang for bucks, and working in the countryside is more expensive, said Mohsina
Bilgrami of the Marie Stopes Society, another nongovernmental organization.
Greenstar is the
country’s largest contraceptive provider, but “we’re a drop in the bucket in a
country of 180 million,” said Shirine Mohagheghpour, the technical adviser for
Greenstar, an affiliate of the Washington-based Population Services
International. “You have to do this community by community.”
Shahid keeps her
message basic. In one colorful illustration she shows on home visits, grimy
children wail in a tattered house. In another, a mother shakes a rattle at a
baby, a father frolics with a toddler and a child reads a book in a tidy
dwelling.
Intrauterine devices
can help make the second picture a reality, she says.
“You can live
tension-free,” she said to a roomful of women in Mirwah. “Your husband will be
happy. Your mother-in-law will be happy. You can pay attention to the children
you already have. If you continue having children year after year, you will get
sick.”
In urban, middle-class
areas, the message is slowly resonating. Two hours away, in the city of Mirpurkhas , a similar talk with women and a few mothers-in-law
sparked boisterous discussion. Several said children were simply too expensive.
“If it’s a sin, there
shouldn’t be doctors who offer it,” one said of contraception, eliciting nods.
At a private clinic in
Mirwah, a woman named Buri, 35, said firmly that a small family is best. But it
was too late: Married at age 13, she was pregnant 12 times before she opted for
tubal ligation, a sterilization procedure. Ten of her children lived. None
attends school.
“They are uninterested
in school,” she said. “Parents are too busy in the fields to pay attention.”
Next to Buri lay her
sister-in-law, silently shivering under a floral sheet, in labor with her first
child. Presiding over the scene was their mother-in-law, a woman in ornate
silver jewelry, who matter-of-factly stated that the newborn should be the
first of at least eight children.